Tech on the Front Lines: New Tools Help FQHCs Close Care Gaps

Federally qualified health centers (FQHCs) are using telehealth and digital health tools to improve access and erase care siloes for millions of underserved Americans

Federally Qualified Health Centers (FQHCs) are often the first point of contact for underserved populations seeking access to care. And often that first impression can make all the difference in accessing care that improves outcomes.

At Kenosha Community Health Center, that first contact is now handled by a nurse who can quickly and efficiently funnel the patient to the right care provider.

“We’re seeing a higher volume of patients with more complex needs, so it’s important that we make this as efficient as possible,” says Mary Ouimet, the Wisconsin-based health center’s CEO. “When you have more than 450 calls a day, that can be a bottleneck.”

Kenosha, part of the Pillar Health network, is one of several FQHCs to collaborate with Conduit Health Partners on nurse triage services. And that’s part of an even larger trend of FQHCs, rural health centers (RHCs), and assorted community health clinics outsourcing some services and using telehealth and digital health technology to alleviate those bottlenecks that keep patients from accessing the care they need.

There are an estimated 1,400 FQHCs and more than 4,400 RHCs in the US, according to the Health and Human Services Department’s Health Resources and Services Administration (HRSA), which supervises funding for those providers. They, along with look-alike (LAL) organizations, provide care and resources for more than 30 million Americans, many of whom can’t afford or access care at a hospital, health systems, or primary care provider.

With the Centers for Medicare & Medicaid Services (CMS) loosening the purse strings on Medicare and Medicaid coverage, these providers are embracing new technologies to improve access to care and resources. At Kenosha, that means instituting a digital nurse triage service that channels the right patients to the right care.

“This is an essential function of the health center,” says Ouimet, who estimates that 100-150 incoming calls a day are now connected to Conduit Health nurses. “These are nurses at the other end who can work with [patients] to coordinate care. The average call time is reduced, and we’re improving time to treatment and bed scheduling. It’s just better care.”

In Massachusetts, meanwhile, an organization serving the commonwealth’s 52 community health centers covering more than 300 sites and 1 million patients is using HRSA grant funding to maintain a technology platform that keeps track of when and where patients receive care. The platform, developed by Bamboo Health, sends real-time notifications to care teams when a patient visits another care provider outside the system, enabling the care team to access admission, discharge and transfer data.

Susan Adams, vice president of health informatics for the Massachusetts League of Community Health Centers, says the technology gives care teams instant digital access to information that would otherwise be siloed away, creating gaps in care that could affect outcomes. She said those care teams had to ask for paper printouts of those visits, then manually enter the data into the patient’s medical record.

“We could be at the printer all day long,” she says.

Thirteen of the Mass League’s CHCs were originally put on Bamboo Health’s platform to monitor some 400,000 patients. According to the organizations, those CHCs saw a 47% reduction in 30-day readmissions among ED patients, a 20% reduction in 30-day readmission among hospitalized patients, and a 33% increase in follow-ups within 30 days of discharge.

The Mass League is now expanding that platform to more CHCs.

“We aren’t getting all the data we need to manage these patients,” Adams says, noting care teams sometimes never learn that a patient has been hospitalized or visited an ED somewhere else unless it comes up in conversation with the patient. The more data we can put into [the patient record] the better chance we have of providing care.”

Having a complete patient record, she says, also helps with chronic care management and strategies to address social determinants of health (SDOH), key care programs that CHCs, FQHCs and other health clinics are being asked to take on.

“I think the challenge will come with managing all of these alerts,” Adams says. “But that’s a good challenge. This gives us a chance to address more care [management and] coordination goals. It’s something that we’ve been waiting a long time to do.”